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Vaginal Cysts and Masses

Vaginal cysts and masses span benign cystic, benign solid, premalignant, and malignant lesions of the vaginal wall and paravaginal tissues. The vast majority are benign and asymptomatic, with vaginal cysts found in roughly 0.5–1% of women. The most common cystic lesions are Müllerian cysts (34–44%), epidermal inclusion cysts (~23%), and Gartner duct cysts (5–11%); the most common periurethral / anterior-wall masses are urethral diverticula (~40%) and Skene gland cysts (~30%).[1][2][3][4][5] Special attention belongs to masses in women over 40 or those that are fixed, painful, or bleeding — malignancy is rare but must be excluded.

For periurethral cystic masses, see also Urethral Diverticulum. For lichen-sclerosus-related vulvovaginal lesions, see Lichen Sclerosus.

Organizational Framework​

CategoryLesions
Embryologic cystsMüllerian, Gartner duct (mesonephric), Skene gland (paraurethral)
Acquired cystsEpidermal inclusion, endometriotic, Bartholin duct
UrologicUrethral diverticulum, ectopic ureterocele, ectopic ureter
Benign solid tumorsLeiomyoma, fibroepithelial stromal polyp, angiomyofibroblastoma, cellular angiofibroma, superficial myofibroblastoma
Locally aggressiveAggressive angiomyxoma
PremalignantVaginal intraepithelial neoplasia (VAIN / vaginal HSIL)
MalignantSquamous cell carcinoma (85–90%), adenocarcinoma, melanoma, sarcoma, metastatic
Iatrogenic / otherMesh-related, pseudocysts, abscesses

Part I — Benign Cystic Lesions​

Müllerian cysts​

  • Most common vaginal cyst in modern series (34–44%)[3][4]
  • Embryology — paramesonephric (Müllerian) duct remnants; lined by mucus-secreting endocervical-type or ciliated tubal-type epithelium[3][4]
  • Location — typically anterolateral vaginal wall
  • Presentation — often larger and more symptomatic than other vaginal cysts; pelvic pressure, dyspareunia, palpable mass
  • Diagnosis — examination + MRI for anatomy; histology shows mucicarmine-positive columnar lining[2][3][15]
  • Management — observation if asymptomatic; excision for symptomatic cysts[2][15]

Gartner duct (mesonephric) cysts​

  • Embryology — mesonephric (Wolffian) duct remnants; non-mucus-secreting cuboidal/low columnar epithelium[3]
  • Prevalence — 5–11% of vaginal cysts (most lesions historically called Gartner duct cysts have mucin and are actually Müllerian)[3][4]
  • Location — anterolateral vaginal wall along the mesonephric remnant[16][17]
  • Presentation — most are small and asymptomatic (38%); when symptomatic: dyspareunia (38%), pelvic pain/pressure (24%), palpable bulge (17%), urinary symptoms (7%); mean size 3.5 cm[18]
  • Diagnostic pitfall: large Gartner duct cysts can mimic anterior compartment prolapse (cystocele) — consider the diagnosis when prolapse compartments don't add up[5][16]
  • Associated GU anomalies in 10–21% — ipsilateral renal agenesis, uterine didelphys, septate vagina, urethral diverticulum, ectopic ureter; reflects shared mesonephric origin[9][17][18]
  • Workup — exam + transvaginal US (most common); MRI for complex / large lesions or to exclude urologic involvement[16][18]

Management options:[17][18]

ApproachNotes
ObservationAsymptomatic
ExcisionMost common (54%); lowest recurrence (~8%)
MarsupializationAlternative for large cysts; no recurrence in one review
Tetracycline sclerotherapy after aspiration7% recurrence
Unroofing / partial excisionNo recurrence reported
Fluorescein dye-assisted excisionIntracystic fluorescein delineates walls and confirms absence of urologic communication[17]

Median follow-up 82 mo: only 1 possible recurrence (3.4%) after excision; no intraoperative complications.[18]

Epidermal inclusion (squamous inclusion) cysts​

  • Second most common vaginal cyst (~23%)[4]
  • Etiology — acquired; squamous epithelium implanted at episiotomy, vaginal laceration, or prior surgery[3][4]
  • Location — posterior or lateral vaginal wall, often at episiotomy scars
  • Histology — keratinizing stratified squamous epithelium with keratinous debris
  • Management — observation; simple excision if symptomatic; no malignant potential[2][3]

Bartholin duct cysts and abscesses​

  • Anatomy — Bartholin glands at posterolateral introitus (4 and 8 o'clock)[19]
  • Lifetime prevalence ~2% of women[19]
  • Pathophysiology — ductal obstruction → cyst; secondary infection → abscess

Management — no single technique is clearly superior; healing and recurrence are similar across fistulization, marsupialization, and sclerotherapy.[19][20]

TechniqueNotes
Word catheterOffice-based; 4–6 weeks for fistulization
MarsupializationPermanent drainage tract
Silver nitrate sclerotherapyAlternative fistulization
I&D / aspiration aloneHigher recurrence — not first-line
Gland excisionRecurrent disease; mandatory consideration in women > 40 to exclude Bartholin gland carcinoma[2][19]

Skene gland (paraurethral) cysts​

  • Embryology — Skene glands are homologs of the male prostate; lined by transitional epithelium[21][22][23]
  • Location — periurethral, adjacent to the meatus[22][24][25]
  • Prevalence — ~30% of periurethral / anterior-wall masses[1]
  • Presentation — dyspareunia (40%), recurrent UTI (40%), vaginal mass, voiding dysfunction, urinary spraying[23][25]
  • Diagnostic pitfall — frequently mislabeled as Bartholin cyst; the discriminator is location (periurethral vs posterolateral introitus). MRI is essential to differentiate from urethral diverticulum.[24][25]
  • Management — surgical excision; cystoscopy to exclude urethral communication; no recurrences in a 10-patient series at mean 3.5 yr[25]

Endometriotic cysts​

  • ~7% of vaginal cysts[4]
  • Location — posterior fornix (most common vaginal endometriosis site) or episiotomy scar[8][4]
  • Presentation — cyclical pain, dyspareunia, dysmenorrhea, tender nodule that enlarges with menses
  • Diagnosis — exam, transvaginal US, MRI for deep infiltrating disease[8]
  • Management — excision for symptomatic lesions; hormonal therapy as adjunct

Ectopic ureter / megaureter presenting as a "vaginal cyst"​

A rare but important pitfall — an ectopic ureter or congenital megaureter can present as a vaginal-wall cyst with continuous incontinence. MRI is essential. Definitive management may require nephroureterectomy with marsupialization of the distal ureter.[9]

Part II — Benign Solid Vaginal Masses​

Benign perivaginal masses account for ~1.6% of urogynecologic surgeries.[6]

Vaginal leiomyoma​

  • Most common benign solid vaginal tumor; smooth muscle origin[8]
  • Painless mass, dyspareunia, urinary symptoms; well-circumscribed, homogeneous on MRI
  • Excision for symptomatic lesions

Fibroepithelial stromal polyp​

  • Benign polypoid lesion of vaginal/vulvar stroma; pedunculated or sessile[10][11]
  • Can be large and edematous, mimicking aggressive angiomyxoma — important diagnostic pitfall[26]
  • Simple excision is curative

Angiomyofibroblastoma (AMFB)​

  • Benign mesenchymal tumor of vulvovaginal region; clinically often mistaken for Bartholin cyst[27]
  • Well-circumscribed; alternating hypercellular / hypocellular zones with abundant capillary-type vessels; vimentin+, desmin+, variable actin[27][28]
  • No recurrence after complete excision — the key distinction from aggressive angiomyxoma[27][29]

Aggressive angiomyxoma (AAM)​

  • Locally aggressive mesenchymal neoplasm of pelvis/perineum in reproductive-age women (mean ~38 yr)[12][30][31]
  • Infiltrative without a true capsule — distinguishes it from AMFB[12][27][29]
  • ER+, PR+, desmin+, vimentin+, variable SMA[30][31]
  • Recurrence 30–40%, sometimes years to decades after excision[12]
  • Essentially no metastatic potential[12][29]
  • Management: wide surgical excision (often difficult given infiltrative nature) + GnRH agonists (or SERMs / aromatase inhibitors) as adjuvant hormonal therapy given ER/PR positivity; long-term surveillance is mandatory[12][30][31]

Other rare benign solid tumors​

Cellular angiofibroma, superficial (cervicovaginal) myofibroblastoma, mammary-type myofibroblastoma — the genital stromal-tumor family; all benign with low recurrence after excision.[10][11] Vaginal angioma and solitary fibrous tumor are rare and curable by excision.[6]

Part III — Vaginal Intraepithelial Neoplasia (VAIN)​

Definition and epidemiology​

  • VAIN is the HPV-related premalignant condition of vaginal squamous epithelium, analogous to CIN and VIN[13][32][14]
  • Rare — < 1% of female genital intraepithelial neoplasias[32]
  • Terminology: VAIN 1 (LSIL) vs VAIN 2/3 (HSIL)[14]
  • Progression to invasive carcinoma ~5% for HSIL (8% in some long-term series)[14][33]
  • Mean age at diagnosis ~55 years[34]

Risk factors​

HPV (especially HPV 16 and 31), prior CIN/cervical cancer, prior hysterectomy (especially for CIN/cancer — 20–55% of VAIN patients have had prior hysterectomy), immunosuppression (HIV), prior pelvic radiation, smoking.[13][14][33][34][35]

Location: > 80% involve the vaginal vault (post-hysterectomy) or upper vagina.[33]

Management[13][32][33][36][37][38][39]​

Grade / optionNotes
VAIN 1 (LSIL)Observation preferred — spontaneous regression in 81–88%
VAIN 2/3 (HSIL)Active treatment indicated
CO₂ laser ablationCure 69–90%; recurrence 6–23%; regression declines with repeated treatments (75% → 53% → 27%); rule out invasion before ablation
Surgical excision (local; upper vaginectomy)Mainstay if invasion cannot be excluded; cure ~69%; margins do not reliably predict residual disease
Topical imiquimod 5%Cure 25–98%; HPV clearance 63% (vs 11% laser, 17% observation); useful for multifocal disease
Topical 5-fluorouracilCure ~46%; multifocal/recurrent and post-radiation patients
BrachytherapyCure 71–90%; refractory/multifocal disease or poor surgical candidates; reserved due to toxicity

Recurrence and progression: ~22% of high-grade VAIN recurs after treatment (risk factors: VAIN 3, prior hysterectomy, excisional treatment); ~1.5% progress to invasive carcinoma at median 87 months — long-term surveillance is mandatory.[34][39]

Part IV — Primary Vaginal Cancer​

Overview​

  • Extremely rare (< 1% of female genital cancers)[40][41][42][43][14]
  • Histology — squamous cell carcinoma 85–90%; adenocarcinoma; melanoma; sarcoma[41][14]
  • HPV-associated (predominantly HPV 16) in most squamous cell carcinomas[14]
  • Mean age sixth decade; rising incidence in younger women with high HIV prevalence[41][42]
  • Presentation — vaginal bleeding (most common), discharge, palpable mass, dyspareunia, urinary symptoms[42][44]

Treatment (NCCN Guidelines)[14][40]​

StageApproach
IDefinitive radiation (preferred) — EBRT + brachytherapy ± concurrent platinum-based chemotherapy; surgical resection only when complete excision with negative margins is feasible without excessive morbidity
II–IVAConcurrent chemoradiation (platinum-based) + brachytherapy
SurgeryReserved for cases where complete resection with clear margins avoids the need for adjuvant RT; definitive surgical management is uncommon

Brachytherapy is a critical component — its addition to EBRT improves survival in stages III–IV.[44]

5-year survival: Stage I 58–84%; Stage II 59–74%; Stage III 67–79%; Stage IV 27–32%.[44][45]

Other rare vaginal malignancies​

HPV-associated adenocarcinoma, clear cell carcinoma (historically DES-associated), endometrioid carcinoma, mesonephric adenocarcinoma, carcinosarcoma, neuroendocrine carcinoma, adenocarcinoma of Skene-gland origin, adenosarcoma, germ cell tumors.[14]

Part V — Diagnostic Approach​

The single most useful diagnostic clue is anatomic location.[2][6][7][8][22]

LocationTop differentials
Anterolateral wallMüllerian cyst, Gartner duct cyst
Periurethral / suburethralUrethral diverticulum, Skene gland cyst
Posterolateral introitus (4–8 o'clock)Bartholin duct cyst
Posterior fornixEndometriotic cyst
Episiotomy scarEpidermal inclusion cyst

Workup:

  1. History — duration, mass sensation, dyspareunia, discharge, voiding dysfunction, incontinence, obstetric history (episiotomy, lacerations), prior pelvic surgery, menstrual cyclicity, age
  2. Examination — location, mobility, tenderness, consistency (cystic vs solid), fixation
  3. Transvaginal / transperineal ultrasound — first-line imaging[6][8]
  4. MRI pelvis — best for complex masses, urethra/bladder/rectum relationships, additional cysts, malignancy exclusion[8][15][16]
  5. VCUG — if urethral diverticulum suspected[7]
  6. Cystourethroscopy — mandatory for periurethral masses to exclude urethral communication[6][25]
  7. Biopsy — solid masses, fixed lesions, women > 40, or any suspicion of malignancy[2]

Management Principles​

  • Asymptomatic benign cysts — observation with periodic follow-up[2][18]
  • Symptomatic benign cysts — surgical excision; marsupialization is an alternative for large Gartner duct or Bartholin cysts[17][18][19]
  • Periurethral masses — preoperative MRI + cystoscopy mandatory to differentiate urethral diverticulum from Skene gland cyst (different operations); de novo SUI in 5.6% after excision; preexisting SUI resolves in ~68%[1]
  • Solid benign tumors — distinguish AMFB (benign, no recurrence) from AAM (locally aggressive, 30–40% recurrence)[12][27]
  • VAIN — low-grade observation; high-grade laser, excision, or topical therapy; long-term surveillance[13][32][39]
  • Malignancy — biopsy any suspicious lesion; refer to gynecologic oncology; vaginal cancer is treated predominantly with chemoradiation + brachytherapy[14][40]

Key Principles​

  • Most vaginal cysts are benign and need no intervention unless symptomatic[2][7]
  • Location is the most important diagnostic clue[3][4]
  • Gartner duct cysts can mimic cystocele — consider when prolapse compartments are inconsistent[5][16]
  • Associated GU anomalies in 10–21% of Gartner duct cysts — image the upper tract[17][18]
  • Rule out malignancy — biopsy in women > 40, fixed masses, or those with pain or bleeding; periurethral / anterior-wall mass malignancy rate ~1.6%[1][2]
  • MRI is the imaging workhorse for complex vaginal masses[8][15][16]
  • Aggressive angiomyxoma is the one benign-appearing vaginal mass with major recurrence risk (30–40%) — wide excision and long-term surveillance[12][31]

References​

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39. He MY, Yu EL, Hui SK, Kung YLF. "Clinical outcomes of laser vaporization for vaginal intraepithelial neoplasia — a 20-year retrospective review." Eur J Obstet Gynecol Reprod Biol. 2022;277:101–109. doi:10.1016/j.ejogrb.2022.08.017

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41. Westerveld H, Nesvacil N, Fokdal L, et al. "Definitive radiotherapy with image-guided adaptive brachytherapy for primary vaginal cancer." Lancet Oncol. 2020;21(3):e157–e167. doi:10.1016/S1470-2045(19)30855-1

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